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R E S E A R C H

Open Access

Brain death and postmortem organ

donation: report of a questionnaire

from the CENTER-TBI study

Ernest van Veen

1,2,3

, Mathieu van der Jagt

1

, Maryse C. Cnossen

2

, Andrew I. R. Maas

4

, Inez D. de Beaufort

3

,

David K. Menon

5

, Giuseppe Citerio

6,7

, Nino Stocchetti

8,9

, Wim J. R. Rietdijk

1

, Jeroen T. J. M. van Dijck

10

,

Erwin J. O. Kompanje

1,3*

and CENTER-TBI investigators and participants

Abstract

Background: We aimed to investigate the extent of the agreement on practices around brain death and postmortem

organ donation.

Methods: Investigators from 67 Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury

(CENTER-TBI) study centers completed several questionnaires (response rate: 99%).

Results: Regarding practices around brain death, we found agreement on the clinical evaluation (prerequisites and

neurological assessment) for brain death determination (BDD) in 100% of the centers. However, ancillary tests were

required for BDD in 64% of the centers. BDD for nondonor patients was deemed mandatory in 18% of the centers

before withdrawing life-sustaining measures (LSM). Also, practices around postmortem organ donation varied

. Organ

donation after circulatory arrest was forbidden in 45% of the centers. When withdrawal of LSM was contemplated, in

67% of centers the patients with a ventricular drain in situ had this removed, either sometimes or all of the time.

Conclusions: This study showed both agreement and some regional differences regarding practices around brain

death and postmortem organ donation. We hope our results help quantify and understand potential differences, and

provide impetus for current dialogs toward further harmonization of practices around brain death and postmortem

organ donation.

Keywords: Traumatic brain injury, Brain death, Ethics, Postmortem organ donation, Withdrawing life-sustaining

measures, Ventricular drainage

Background

Before the 1950s, death was only determined using

cardiovascular criteria. Due to advances in critical care

medicine, especially mechanical ventilation, a new

clinical state was observed in 1958 (i.e.,

“coma dépassé”)

[

1

]. Although the systemic circulation was intact, the

brain showed no objective evidence of function. This

observation gave rise to the question of what

“coma

dépassé

” meant. The successful transplantation of

kid-neys from a

“coma dépassé” patient (1965) subsequently

led to the first accepted standard for the confirmation of

brain death in 1968 [

2

]. In 1981, the Uniform

Determin-ation of Death Act made death determined by

neuro-logical and cardiovascular criteria equivalent [

3

]. The

American Academy of Neurology (AAN) in 1995

pub-lished guidelines for brain death determination (BDD)

[

4

], and updated these in 2010 [

5

]. In 2008, the Academy

of Medical Royal Colleges in the United Kingdom (UK)

provided broader guidance on the determination of

death in a range of circumstances, including BDD [

6

].

Brain death and postmortem organ donation are closely

linked. Also, an important, and not well investigated, issue

* Correspondence:e.j.o.kompanje@erasmusmc.nl

1

Department of Intensive Care, Erasmus University Medical Center, Rotterdam, the Netherlands

3Department of Medical Ethics and Philosophy of Medicine, Erasmus

University Medical Center, Rotterdam, the Netherlands

Full list of author information is available at the end of the article

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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regarding circulatory arrest organ donation is the

hands-off time after circulatory arrest. Practices around all

of these mentioned topics are delicate. Thus,

inconsisten-cies between centers can be confusing for the general

public, and could expose clinicians to accusations of

unethical practice. Consensus regarding practices around

brain death and postmortem organ donation could

prevent these inconsistencies. To facilitate this consensus,

the first step is to document potential differences.

The Collaborative European NeuroTrauma

Effective-ness Research in Traumatic Brain Injury (CENTER-TBI,

www.center-tbi.eu

) study addressed this issue. The

CENTER-TBI study used questionnaires to create

“pro-vider profiles” of participating neurotrauma centers. One

of these questionnaires intended to address specific

practices around brain death and postmortem organ

donation that currently provoke international discussion.

Using this questionnaire, we aimed to quantify and

understand potential differences, and provide impetus

for current dialogs toward further harmonization of

prac-tices around brain death and postmortem organ donation.

Regarding brain death, we investigated: criteria used for

BDD; and the necessity of BDD before withdrawing

life-sustaining measures (LSM). As for postmortem organ

donation, we investigated: removal of the ventricular drain

while continuing other LSM; the possibility for circulatory

arrest organ donation; and the hands-off time after

circulatory arrest.

Methods

CENTER-TBI and study sample

The CENTER-TBI study includes a prospective

observa-tional study on traumatic brain injury (TBI) [

7

,

8

]. The

investigators connected to this study collect data on

pa-tient characteristics, management, and outcomes in

im-portant centers from 20 countries across Europe and

Israel. Investigators from all participating centers in the

CENTER-TBI study were asked to complete several

questionnaires. Centers were located in Austria (N = 2),

Belgium

(N = 4), Bosnia and Herzegovina (N = 2),

Denmark

(N = 2), Finland (N = 2), France (N = 7),

Germany (N = 4), Hungary (N = 2), Israel (N = 2), Italy

(N = 8), Latvia (N = 3), Lithuania (N = 2), the Netherlands

(N = 7), Norway (N = 3), Romania (N = 1), Serbia (N = 1),

Spain (N = 4), Sweden (N = 2), Switzerland (N = 1), and

the UK (N = 8).

Questionnaire development and administration

More detailed information about the development,

ad-ministration, and content of the questionnaires is

avail-able from an earlier publication by Cnossen et al. [

9

].

The topics covered in the current study are

summa-rized in Table

1

. A complete overview of the

question-naires for this study can be found in Additional file

1

:

Questionnaire 1 (questions 1, 4, 8, and 9), 7 (questions 2

and 4), and 8 (questions 9 and 11–15). In the

question-naires, we explicitly asked for the

“general policy”

ac-cording to the investigators. We defined this as the local

standards used in more than 75% of patients,

recogniz-ing that there might be exceptions. Most questions made

use of categorical answer categories. For some questions,

the investigators had the option to fill in an answer that

could be different from one of the options provided.

These answers were marked as

“other” and consisted of

free text responses. Where these free text responses

from different investigators were sufficiently similar, we

sought

to

combine

them

to

provide

additional

categorical responses. We did this to facilitate summary

descriptive statistics.

Analyses

We used descriptive statistics to describe our outcomes.

We calculated frequencies and percentages for all

variables related to the number of responses for that

question. Centers at which the investigator did not

respond to every question remained in our study, in

order to keep groups for descriptive statistics as large as

possible. The response rates per question are presented

in Table

1

. We grouped countries into seven regions:

Baltic States (Latvia and Lithuania), Eastern Europe

(Bosnia and Herzegovina, Hungary, Romania, and

Serbia), Israel, Northern Europe (Denmark, Finland,

Norway, and Sweden), Southern Europe (Italy and

Spain), the United Kingdom, and Western Europe

(Austria, Belgium, France, Germany, the Netherlands,

and Switzerland). We examined potential differences

between and within regions.

Results

Center characteristics

Of the 68 centers, investigators from 67 centers participated

in the questionnaires (response rate: 99%) and were

in-cluded in the analysis. The participating centers were

mainly academic centers (N = 61, 91%), designated as a

level I or II trauma center (N = 49, 73%). The average

num-ber of beds in the participating centers was 1187, of which

on average 39 were intensive care unit (ICU) beds. The

average number of annual treatments per ICU in 2013 was

1408, of which on average 130 were TBI patients.

Practices around brain death

When do you declare a patient brain dead?

We found agreement on the clinical evaluation

(prerequi-sites and neurological assessment) for BDD in 100% of the

centers. The clinical evaluation for BDD included: a

Glasgow Coma Scale (GCS) of three, absence of brain

stem reflexes, no respiratory efforts in response to an

apnea test, and absence of confounding factors to

(3)

evaluate consciousness (e.g., hypothermia). However,

ancillary tests were required for BDD in 43 (64%)

centers (Table

2

).

In three regions (43%; Israel, Southern Europe, and the

UK), the same criteria for BDD were used in every

cen-ter of the same region. In cencen-ters from Northern Europe

and the UK, ancillary tests were rarely used for BDD (N

= 2, 22% and

N = 0, 0%, respectively).

Must the patient, who is not suitable for organ donation,

be declared brain dead before withdrawing LSM?

The declaration of brain death in nondonor patients was

mandatory before withdrawing LSM in 12 (18%) centers. In

41 (61%) centers, a poor prognosis as assessed by the

treat-ing physician(s) was considered sufficient. In 9 (13%)

cen-ters, a GCS score of three, fixed dilated pupils, and absence

of confounders could motivate withdrawing LSM (Table

2

).

Table 1 Topics covered, related questions for each topic, and response rate per question

Topics covered in this study Questions related to this topic Response rate,

N (%) Practices around brain death

Criteria for BDD When do you declare a patient brain dead? 67 (99%)

Brain death and withdrawal of LSM Must the patient, who is not suitable for organ donation, be declared brain dead before withdrawing life-sustaining measures?

67 (99%) Practices around postmortem organ donation

Donation after circulatory death Would you consider organ donation after circulatory arrest in a patient in whom mechanical ventilation will be withdrawn, but who is not brain dead?

66 (97%)

Ventricular drain removal and organ donation If the decision is made to withdraw life-sustaining measures, in a pa-tient with high intracranial pressure, but who is not brain dead, would you remove the ventricular drain (for CSF drainage), but con-tinue other life-sustaining measures in the hope that the patient will become brain dead and thereby becomes a suitable candidate for organ donation?

67 (99%)

Declaration of death and hands-off time in

donors and nondonors After withdrawal of mechanical ventilation and after circulatory arrest,when exactly do you declare the patient dead in case of a circulatory death organ donor?

64 (94%)

After withdrawal of mechanical ventilation and after circulatory arrest, after how many minutes circulatory arrest do you declare the patient dead in cases not suitable as organ donor?

66 (97%)

BDD brain death determination, CSF cerebrospinal fluid, LSM life-sustaining measures

Table 2 Practices around brain death

Region Answer Sample total (N = 67) Baltic States (N = 5) Eastern Europe (N = 6) Israel (N = 2) Northern Europe (N = 9) Southern Europe (N = 12) United Kingdom (N = 8) Western Europe (N = 25) When do you declare a patient brain dead?

With GCS 3, fixed dilated pupils, and no confounding factors (e.g., hypothermia, barbiturates)

0 0 0 0 0 0 0 0

With GCS 3 and absent brain stem reflexes, and no confounding factors

0 0 0 0 0 0 0 0

With GCS 3, absent brain stem reflexes and apnea, and no confounding factors

31 20 17 0 78 0 88 20

With GCS 3, absent brain stem reflexes, apnea and ancillary test(s) (e.g., EEG or cerebral angiography), and absence of confounding factors

64 80 83 100 22 100 0 72

Per national protocola 4 0 0 0 0 0 13 8

Must the patient, who is not suitable for organ donation, be declared brain dead before withdrawing LSM?

No, the prospect of a very poor prognosis can be enough 61 0 17 0 78 42 100 80

No, GCS 3 and fixed dilated pupils and no confounders is enough to stop treatment

13 0 0 50 22 8 0 20

Yes, this is mandatory by law in my country 18 80 17 50 0 50 0 0

Yes, it is not mandatory by law, but I always do that to be sure 7 20 67 0 0 0 0 0

Data presented as percentage

EEG electroencephalography, GCS Glasgow Coma Scale, LSM life-sustaining measures

aAdditional categorical responses, while free text responses were sufficiently similar. This does not mean that the other centers do not follow their

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In all centers in the Baltic States (N = 5), nondonor

patients were declared brain dead before withdrawing

LSM. In several centers in Eastern Europe and

South-ern Europe (N = 1, 17% and N = 6, 50%, respectively),

it was mandatory to declare a patient brain dead

be-fore withdrawing LSM in nondonor patients, whereas

in other centers from the same region this was not

mandatory.

Practices around postmortem organ donation

Would you consider organ donation after circulatory arrest

in a patient in whom mechanical ventilation will be

withdrawn, but who is not brain dead?

Organ donation after circulatory arrest was forbidden in

30 (45%) centers (Fig.

1

and Table

3

).

In all centers in the UK (N = 8), postmortem organ

donation after circulatory arrest was approved. In centers

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Sample total (N=66) Baltic States (N=5) Eastern Europe (N=6)

Israel (N=2) Northern Europe (N=9) Southern Europe (N=12) United Kingdom (N=8) Western Europe (N=24) No, this is forbidden in my country No, although it would be permitted, I would not do this Yes, sometimes Yes, always

Fig. 1 Results of question 13 (Questionnaire 8): Would you consider organ donation after circulatory arrest in a patient in whom mechanical ventilation will be withdrawn, but who is not brain dead?

Table 3 Practices around circulatory arrest organ donation and ventricular drain removal

Region Answer Sample total (N = 66) Baltic States (N = 5) Eastern Europe (N = 6) Israel (N = 2) Northern Europe (N = 9) Southern Europe (N = 12) United Kingdom (N = 8) Western Europe (N = 24) Would you consider organ donation after circulatory arrest in a patient in whom mechanical ventilation will be withdrawn, but who is not brain dead?

No, this is forbidden in my country 45 80 67 50 67 42 0 42

No, although it would be permitted, I would not do this

15 20 33 0 22 33 0 4 Yes, sometimes 20 0 0 50 11 25 13 29 Yes, always 20 0 0 0 0 0 88 25 Sample total (N = 67) Baltic States (N = 5) Eastern Europe (N = 6) Israel (N = 2) Northern Europe (N = 9) Southern Europe (N = 12) United Kingdom (N = 8) Western Europe (N = 25) If the decision is made to withdraw life-sustaining measures, in a patient with high intracranial pressure, but who is not brain dead, would you remove the ventricular drain (for CSF drainage), but continue other life-sustaining measures in the hope that the patient will become brain dead and then becomes a suitable candidate for organ donation?

No, never 33 80 33 0 0 17 88 28

Yes, sometimes 51 20 50 100 100 50 13 48

Yes, always 16 0 17 0 0 33 0 24

Data presented as percentage CSF cerebrospinal fluid

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in the Baltic States, Eastern Europe, and Northern Europe,

organ donation after circulatory arrestwas often forbidden

(N = 4, 80%; N = 4, 67% and N = 6, 67% respectively).

If the decision is made to withdraw life-sustaining measures,

in a patient with high intracranial pressure, but who is not

brain dead, would you remove the ventricular drain (for CSF

drainage), but continue other life-sustaining measures in the

hope that the patient will become brain dead and thereby

becomes a suitable candidate for organ donation?

In 45 (67%) centers, the ventricular drain was sometimes

or always removed. In 11 of these 45 centers (16% of the

Sample total), the ventricular drain was always removed

while continuing other LSM. In 22 (33%) centers, the

ventricular drain was never removed while continuing

other LSM (Fig.

2

and Table

3

).

In 4 (80%) centers in the Baltic States and in 7 (88%)

cen-ters in the UK, the ventricular drain was never removed. In

all centers from Israel (N = 2) and Northern Europe (N = 9),

the ventricular drain was

“sometimes” removed.

After withdrawal of mechanical ventilation and after

circulatory arrest, when exactly do you declare the patient

dead in case of a circulatory death organ donor, and in

cases not suitable as an organ donor?

In the case of a circulatory death organ donor, it was most

common (N = 15, 23%) to declare the patient dead after

5-min

“flatliner-ECG”. In cases not suitable as an organ

donor, it was most common (N = 21, 32%) to declare the

patient dead directly after detection of a

“flatliner-ECG”

on the monitor (Table

4

).

In all centers in Israel, nondonor patients were

de-clared dead directly after detection of a

“flatliner-ECG”

on the monitor. No other region had the same answer in

every center concerning the declaration of death in

donor and nondonor patients.

Discussion

We aimed to investigate specific practices that currently

provoke international discussion in the area of brain

death and postmortem organ donation. We aimed to

quantify and understand potential differences, and

pro-vide

impetus

for

current

dialogs

toward

further

harmonization of practices around brain death and

postmortem organ donation.

Taking all results together, we found agreement on the

clinical evaluation (prerequisites and neurological assess

ment) for brain death determination (BDD) across regions.

In addition to this clinical evaluation, ancillary tests were

re-quired for BDD in 64% of the centers. BDD was deemed

mandatory before withdrawal of life-sustaining measures

(LSM) even outside the context of organ donation in 18%

of the centers. As for practices around postmortem organ

donation across regions, in 67% of the centers a ventricular

drain was sometimes or always removed while other LSM

were continued. Last, in 45% of the centers organ donation

after circulatory arrest was forbidden.

We found important agreement and some differences

regarding practices around brain death. Due to the broad

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Sample total (N=67) Baltic States (N=5) Eastern Europe (N=6)

Israel (N=2) Northern Europe (N=9) Southern Europe (N=12) United Kingdom (N=8) Western Europe (N=25) No, never Yes, sometimes Yes, always

Fig. 2 Results of question 9 (Questionnaire 8): If the decision is made to withdraw life-sustaining measures, in a patient with high intracranial pressure, but who is not brain dead, would you remove the ventricular drain (for CSF drainage), but continue other life-sustaining measures in the hope that the patient will become brain dead and thereby becomes a suitable candidate for organ donation?

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categorical answer possibilities provided, the application

of these findings is limited. First, agreement existed in all

centers on the clinical evaluation for BDD, namely a

Glas-gow Coma Scale (GCS) of three, absence of brain stem

re-flexes, no respiratory efforts in response to an apnea test,

and absence of confounding factors to evaluate

conscious-ness. This is promising, in the light of recent calls to reach

a worldwide consensus on how to determine brain death

[

10

]. However, in addition to this clinical evaluation,

ancil-lary tests were reported to be required for BDD in two

thirds of centers. These differences in the use of ancillary

tests are in line with previous literature [

11

19

].

Interest-ingly, however, there have been calls to abandon ancillary

tests for BDD [

20

]. In the majority of centers from

North-ern Europe and the United Kingdom (UK), ancillary tests

were not mandatory for BDD. This is in line with the

study by Wahlster et al. [

11

]. These discrepancies may

suggest differences in ethical principles and regulatory

practice between centers. In some centers it was

mandatory to declare nondonor patients brain dead before

Table 4 Practices around the hands-off time after circulatory arrest

Region Answer Sample total (N = 64) Baltic States (N = 5) Eastern Europe (N = 6) Israel (N = 2) Northern Europe (N = 9) Southern Europe (N = 12) United Kingdom (N = 8) Western Europe (N = 22) After withdrawal of mechanical ventilation and after circulatory arrest, when exactly do you declare the patient dead in case of a circulatory death organ donor?

Directly after circulatory arrest determined after a

“flatliner-ECG” on the monitor 16 40 0 50 11 8 0 23

After 1-min“flatliner-ECG” indicating circulatory arrest 5 0 0 50 0 8 0 5

After 2-min“flatliner-ECG” 2 0 0 0 0 0 0 5

After 5-min“flatliner-ECG” 23 20 33 0 11 17 50 23

After 10-min“flatliner-ECG” 5 20 17 0 0 0 0 5

After loss of pulsatile arterial curve on the invasive arterial blood pressure tracing

6 20 17 0 0 0 0 9

After 20-min“flatliner-ECG”a 11 0 0 0 0 58 0 0

Not done in our hospital/countrya 19 0 17 0 78 0 0 18

Other, please specifyb 14 0 17 0 0 8 50 14

Sample total (N = 66) Baltic States (N = 5) Eastern Europe (N = 6) Israel (N = 2) Northern Europe (N = 9) Southern Europe (N = 12) United Kingdom (N = 8) Western Europe (N = 24) After withdrawal of mechanical ventilation and after circulatory arrest, after how many minutes circulatory arrest do you declare the patient dead in cases not suitable as organ donor?

Directly after circulatory arrest determined after a

“flatliner-ECG” on the monitor 32 40 17 100 11 17 13 50

After 1-min“flatliner-ECG” indicating circulatory arrest 5 0 0 0 0 0 0 13

After 2-min“flatliner-ECG” 0 0 0 0 0 0 0 0

After 5-min“flatliner-ECG” 23 20 17 0 22 25 38 21

After 10-min“flatliner-ECG” 6 20 33 0 0 0 0

After loss of pulsatile arterial curve on the invasive arterial blood pressure tracing

6 20 33 0 11 0 0 0

After 20-min“flatliner-ECG”a 9 0 0 0 0 50 0 0

Not done in our hospital/countrya 8 0 0 0 33 0 0 8

Other, please specifyc 12 0 0 0 22 0 50 8

Data presented as percentage EEG electroencephalography

a

Additional categorical responses, while free text responses were sufficiently similar

b

Specifications filled in under“other”: “two minutes after loss of pulsatile arterial curve on the invasive arterial blood pressure tracing”; “after 3 min”; “No carotid pulses and apnoea”; “absence central pulse for 5 mins confirmed by observation for further 5 mins”; “National guidance 5 mins mechanical asystole”; “apnea test positivity”; “according to the Dutch law on organ donation”; “Protokollbogen zur Feststellung des irreversiblen Hirnfunktionsausfalls”; “at the beginning of the commission observation (6 h before)”

c

Specifications filled in under“other”: “Control 10 min later”; “After clinical death diagnosis: listen to heart sound, examination of pupils”; “At decision of the physician”; “No carotid pulses and apnoea”; “absence central pulse for 5 mins confirmed by observation for further 5 mins”; “apnea test positivity”; “according to the Dutch law on organ donation”; “Protokollbogen zur Feststellung des irreversiblen Hirnfunktionsausfalls”; “at the beginning of the commission observation (6 h before)”

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withdrawing life-sustaining measures (LSM). Withdrawal

of LSM and the declaration of brain death are two

differ-ent processes. The obligation of BDD before limiting

treatment is debatable, since many non-brain dead

pa-tients may have a hopeless prognosis rendering further

treatment futile.

We also found differences regarding practices around

postmortem organ donation. First, we found differences

concerning the removal of the ventricular drain. Our

questionnaire did not assess in-depth the reasons why

some centers opted to discontinue drainage and remove

the ventricular drain as compared to maintaining the

de-vice in place, and how such continued intervention was

incorporated into the care plan. Second, we found

differ-ences with regard to the possibility for organ donation

after circulatory arrest. These results are in line with

previous literature [

21

,

22

]. The ventricular drain

(men-tioned earlier in this paragraph) seemed to be removed

more often in centers where donation after circulatory

arrest was not possible. If this turns out to be general

practice, this might indicate the need for reevaluation of

organ donation after circulatory arrest in order to

pre-vent future burdensome care. For international figures

on donation and transplantation, we refer the reader to

the Newsletter Transplant 2017 produced by the Council

of Europe of the European Committee [

23

]. There are

no specific figures available for the centers involved in

the Collaborative European NeuroTrauma Effectiveness

Research in Traumatic Brain Injury (CENTER-TBI)

study. Although the CENTER-TBI study includes

im-portant neurotrauma centers, we do not know to what

extent these centers are responsible for the investigated

figures of the Council of Europe. For the countries

involved in our study, the number of donations after

brain death in 2016 varied between 1.3 per million

in-habitants (Bosnia and Herzegovina) and 33.1 per million

inhabitants (Spain) [

23

]. Third, we found differences in

hands-off times needed after circulatory arrest in order

to declare a patient dead. This could indicate a lack of

clear evidence on the exact time needed to be sure the

brain has irreversibly lost its function.

Some of the differences appear region specific, but for

other aspects we found variation between centers within

a single region. Differences were even noted between

re-gions participating in Eurotransplant, an organization

that aims to optimally distribute organs by transplanting

across national borders, when no matching recipient is

available on the waiting list in the donor’s country.

Eurotransplant covers part of Europe, and includes eight

countries: Austria, Belgium, Croatia, Germany, Hungary,

the Netherlands, Luxembourg, and Slovenia. The

differ-ences found pertained to all topics covered in this study.

Present-day medicine is said to be affected by the

cultural climate of the society in which it exists [

24

].

This may indicate that differences in culture could

explain some of the observed variation. Other results,

such as possibilities for organ donation after circulatory

arrest, suggest that variations have a more legal or

regu-latory basis. Observed within-region differences which

suggest a more legal or regulatory basis raise questions

regarding the level of enforcement of pertinent laws, and

may indicate a lack of knowledge, regulatory

implemen-tation, or ambiguous legislation.

This study has several limitations that should be

con-sidered when interpreting the results. First, the

partici-pating neurotrauma centers represent a select group.

The data obtained may therefore not be representative

for all neurotrauma centers within the geographical

areas studied. Second, our sample size made it difficult

to apply more advanced statistics, such as a chi-square

test, cluster analysis, and multidimensional scaling.

Third, the results are based on the perceptions of

prac-tices reported by specific investigators rather than on

clinical data. The CENTER-TBI study will further clarify

actual practices around brain death and postmortem

organ donation by analyzing clinical data. Fourth,

inves-tigators may have interpreted some questions incorrectly

because a questionnaire does not always permit the

nuances appropriate for clinical practice. In clinical

practice, potential alternative options are both more

numerous and complex than can be captured by a

questionnaire. Last, investigators may have presented

(even unwittingly) a more favorable image or presented

individual preferences instead of the general policy in a

center that we asked for.

Future research should focus on extending this study

to a larger group of neurotrauma centers across the

world in order to examine (in more advanced statistics)

whether our results also apply to other centers.

Further-more, it would be interesting to study the origin of the

differences found (e.g., cultural differences and differences

pertaining to legislation). The complexity of some of the

drivers of reported practice makes the case for mixed

methods approaches to this problem, with a potentially

substantive role for qualitative research methods. These

strategies are important in order to inform preferred

ap-proaches to improve harmonization in neurotrauma

cen-ters across Europe and Israel.

Most importantly, current dialogs should be continued,

and we hope that our findings may provide a basis toward

further harmonization of practices around brain death

and postmortem organ donation.

Conclusion

This study showed both agreement and some regional

differences regarding practices around brain death and

postmortem organ donation. We hope our results help

quantify and understand potential differences, and

(8)

provide impetus for current dialogs toward further

harmonization of practices around brain death and

post-mortem organ donation.

Additional file

Additional file 1:Provider profiling questionnaires used for this study (Questionnaires 1, 7, and 8). (PDF 596 kb)

Abbreviations

AAN:American Academy of Neurology; BDD: Brain death determination; CENTER-TBI: Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury; CSF: Cerebrospinal fluid; ECG: Electrocardiography; GCS: Glasgow Coma Scale; ICU: Intensive care unit; LSM: Life-sustaining measures; TBI: Traumatic brain injury; UK: United Kingdom

Acknowledgements

Cecilia Ackerlund1, Hadie Adams2, Vanni Agnoletti3, Judith Allanson4, Krisztina Amrein5, Norberto Andaluz6, Nada Andelic7, Lasse Andreassen8, Azasevac

Antun9, Audny Anke10, Anna Antoni11, Hilko Ardon12, Gérard Audibert13,

Kaspars Auslands14, Philippe Azouvi15, Maria Luisa Azzolini16, Camelia Baciu17,

Rafael Badenes18, Ronald Bartels19, Pál Barzó20, Ursula Bauerfeind21, Romuald Beauvais22, Ronny Beer23, Francisco Javier Belda18, Bo-Michael Bellander24,

Antonio Belli25, Rémy Bellier26, Habib Benali27, Thierry Benard26, Maurizio

Berardino28, Luigi Beretta16, Christopher Beynon29, Federico Bilotta18, Harald

Binder11, Erta Biqiri17, Morten Blaabjerg30, Hugo den Boogert19, Pierre Bouzat31, Peter Bragge32, Alexandra Brazinova33, Vibeke Brinck34, Joanne

Brooker35, Camilla Brorsson36, Andras Buki37, Monika Bullinger38, Emiliana

Calappi39, Maria Rosa Calvi16, Peter Cameron40, Guillermo Carbayo Lozano41,

Marco Carbonara39, Elsa Carise26, K. Carpenter42, Ana M. Castaño-León43, Francesco Causin44, Giorgio Chevallard17, Arturo Chieregato17, Giuseppe

Citerio45,46, Maryse Cnossen47, Mark Coburn48, Jonathan Coles49, Lizzie

Coles-Kemp50, Johnny Collett50, Jamie D. Cooper51, Marta Correia52, Amra Covic53,

Nicola Curry54, Endre Czeiter55, Marek Czosnyka56, Claire Dahyot-Fizelier26, François Damas57, Pierre Damas58, Helen Dawes59, Véronique De Keyser60,

Francesco Della Corte61, Bart Depreitere62, Godard C. W. de Ruiter63, Dula

Dilvesi9, Shenghao Ding64, Diederik Dippel65, Abhishek Dixit66, Emma

Donoghue40, Jens Dreier67, Guy-Loup Dulière57, George Eapen68, Heiko Enge-mann53, Ari Ercole66, Patrick Esser59, Erzsébet Ezer69, Martin Fabricius70, Valery

L. Feigin71, Junfeng Feng64, Kelly Foks65, Francesca Fossi17, Gilles Francony31,

Ulderico Freo72, Shirin Frisvold73, Alex Furmanov74, Pablo Gagliardo75, Damien

Galanaud27, Dashiell Gantner40, Guoyi Gao76, Karin Geleijns42, Pradeep George1, Alexandre Ghuysen77, Lelde Giga78, Benoit

Giraud26, Ben Glocker79, Jagos Golubovic9, Pedro A. Gomez43, Francesca

Grossi61, Russell L. Gruen80, Deepak Gupta81, Juanita A. Haagsma47, Iain

Haitsma82, Jed A. Hartings83, Raimund Helbok23, Eirik Helseth84, Daniel Hertle30, Astrid Hoedemaekers85, Stefan Hoefer53, Lindsay Horton86, Jilske

Huijben47, Peter J. Hutchinson2, Asta Kristine Håberg87, Bram Jacobs88, Stefan

Jankowski68, Mike Jarrett34, Bojan Jelaca9, Ji-yao Jiang76, Kelly Jones89,

Konstantinos Kamnitsas79, Mladen Karan6, Ari Katila90, Maija Kaukonen91, Thomas Kerforne26, Riku Kivisaari91, Angelos G. Kolias2, Bálint Kolumbán92,

Erwin Kompanje93, Ksenija Kolundzija94, Daniel Kondziella70, Lars-Owe

Koski-nen36, Noémi Kovács92, Alfonso Lagares43, Linda Lanyon1, Steven Laureys95,

Fiona Lecky96, Christian Ledig79, Rolf Lefering97, Valerie Legrand98, Jin Lei64, Leon Levi99, Roger Lightfoot100, Hester Lingsma47, Dirk Loeckx101, Angels

Lozano18, Andrew I. R. Maas60, Stephen MacDonald102, Marc Maegele103,

Marek Majdan33, Sebastian Major104, Alex Manara105, Geoffrey Manley106,

Didier Martin107, Leon Francisco Martin101, Costanza Martino3, Armando Maruenda18, Hugues Maréchal57, Alessandro Masala3, Julia Mattern29, Charles

McFadyen66, Catherine McMahon108, Béla Melegh109, David Menon66, Tomas

Menovsky60, Cristina Morganti-Kossmann110, Davide Mulazzi39, Visakh

Muraleedharan1, Lynnette Murray40, Holger Mühlan111, Nandesh Nair60, Ancuta Negru112, David Nelson1, Virginia Newcombe66, Daan Nieboer47,

Quentin Noirhomme95, József Nyirádi5, Mauro Oddo113, Annemarie

Oldenbeuving114, Matej Oresic115, Fabrizio Ortolano39, Aarno Palotie116,117,118,

Paul M. Parizel119, Adriana Patruno120, Jean-François Payen31, Natascha Perera22, Vincent Perlbarg27, Paolo Persona121, Wilco Peul63, Anna

Piippo-Karjalainen91, Sébastien Pili Floury122, Matti Pirinen116, Horia Ples112, Maria

Antonia Poca123, Suzanne Polinder47, Inigo Pomposo41, Jussi Posti90, Louis

Puybasset124, Andreea Radoi123, Arminas Ragauskas125, Rahul Raj91, Malinka

Rambadagalla126, Ruben Real53, Veronika Rehorčíková33, Jonathan Rhodes127,

Samuli Ripatti116, Saulius Rocka125, Cecilie Roe128, Olav Roise129, Gerwin

Roks130, Jonathan Rosand131, Jeffrey Rosenfeld110, Christina Rosenlund132, Guy Rosenthal74, Rolf Rossaint48, Sandra Rossi121, Daniel Rueckert79, Martin

Rusnák133, Marco Sacchi17, Barbara Sahakian66, Juan Sahuquillo123, Oliver

Sakowitz134,135, Francesca Sala120, Renan Sanchez-Porras134, Janos Sandor136,

Edgar Santos29, Luminita Sasu61, Davide Savo120, Nadine Schäffer103, Inger Schipper137, Barbara Schlößer21, Silke Schmidt111, Herbert Schoechl138, Guus

Schoonman130, Rico Frederik Schou139, Elisabeth Schwendenwein11, Michael

Schöll29, Özcan Sir140, Toril Skandsen141, Lidwien Smakman63, Dirk Smeets101,

Peter Smielewski56, Abayomi Sorinola142, Emmanuel Stamatakis66, Simon Stanworth54, Nicole Steinbüchel143, Ana Stevanovic48, Robert Stevens144,

William Stewart145, Ewout W. Steyerberg47,146, Nino Stocchetti147, Nina

Sundström36, Anneliese Synnot34,148, Fabio Silvio Taccone18, Riikka Takala90,

Viktória Tamás142, Päivi Tanskanen91, Mark Steven Taylor33, Braden Te Ao71, Olli Tenovuo90, Ralph Telgmann53, Guido Teodorani149, Alice Theadom71,

Matt Thomas105, Dick Tibboel42, Christos Tolias150, Jean-Flory Luaba

Tshibanda151, Tony Trapani40, Cristina Maria Tudora112, Peter Vajkoczy67,

Shirley Vallance43, Egils Valeinis78, Gregory Van der Steen60, Mathieu van der Jagt152, Joukje van der Naalt88, Jeroen T. J. M. van Dijck63, Thomas A. van

Essen63, Wim Van Hecke101, Caroline van Heugten59, Dominique Van Praag60,

Thijs Vande Vyvere101, Julia Van Waesberghe48, Audrey Vanhaudenhuyse27,95,

Alessia Vargiolu120, Emmanuel Vega153, Kimberley Velt47, Jan Verheyden101, Paul M. Vespa154, Anne Vik155, Rimantas Vilcinis156, Giacinta Vizzino17, Carmen

Vleggeert-Lankamp63, Victor Volovici82, Daphne Voormolen47, Peter

Vulekovic9, Zoltán Vámos69, Derick Wade59, Kevin K. W. Wang157, Lei Wang64,

Lars Wessels158, Eno Wildschut42, Guy Williams66, Lindsay Wilson86, Maren K. L. Winkler104, Stefan Wolf158, Peter Ylén159, Alexander Younsi29, Menashe

Zaaroor99, Yang Zhihui160, Agate Ziverte78, Fabrizio Zumbo3.

1Karolinska Institutet, INCF International Neuroinformatics Coordinating

Facility, Stockholm, Sweden.

2Division of Neurosurgery, Department of Clinical Neurosciences,

Addenbrooke’s Hospital & University of Cambridge, Cambridge, UK.

3Department of Anesthesia & Intensive Care, M. Bufalini Hospital,

Cesena, Italy.

4Department of Clinical Neurosciences, Addenbrooke’s Hospital & University

of Cambridge, Cambridge, UK.

5János Szentágothai Research Centre, University of Pécs, Pécs, Hungary. 6

University of Cincinnati, Cincinnati, OH, USA.

7Division of Surgery and Clinical Neuroscience, Department of Physical

Medicine and Rehabilitation, Oslo University Hospital and University of Oslo, Oslo, Norway.

8

Department of Neurosurgery, University Hospital Northern Norway, Tromsø, Norway.

9

Department of Neurosurgery, Clinical Centre of Vojvodina, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia.

10

Department of Physical Medicine and Rehabilitation, University Hospital Northern Norway.

11

Trauma Surgery, Medical University Vienna, Vienna, Austria.

12Department of Neurosurgery, Elisabeth-TweeSteden Ziekenhuis, Tilburg,

the Netherlands.

13Department of Anesthesiology & Intensive Care, University Hospital Nancy,

Nancy, France.

14Riga Eastern Clinical University Hospital, Riga, Latvia. 15

Raymond Poincaré Hospital, Assistance Publique—Hopitaux de Paris, Paris, France.

16

Department of Anesthesiology & Intensive Care, S Raffaele University Hospital, Milan, Italy.

17

NeuroIntensive Care, Niguarda Hospital, Milan, Italy.

18Department Anesthesiology and Surgical-Trauma Intensive Care, Hospital

Clinic Universitari de Valencia, Spain.

19

Department of Neurosurgery, Radboud University Medical Center, Nijmegen, the Netherlands.

20Department of Neurosurgery, University of Szeged, Szeged, Hungary. 21

Institute for Transfusion Medicine (ITM), Witten/Herdecke University, Cologne, Germany.

22

International Projects Management, ARTTIC, München, Germany.

23Department of Neurology, Neurological Intensive Care Unit, Medical

(9)

24Department of Neurosurgery & Anesthesia & Intensive Care Medicine,

Karolinska University Hospital, Stockholm, Sweden.

25NIHR Surgical Reconstruction and Microbiology Research Centre,

Birmingham, UK.

26Intensive Care Unit, CHU Poitiers, Poitiers, France.

27Anesthesie-Réanimation, Assistance Publique—Hopitaux de Paris, Paris,

France.

28

Department of Anesthesia & ICU, AOU Città della Salute e della Scienza di Torino—Orthopedic and Trauma Center, Torino, Italy.

29Department of Neurosurgery, University Hospital Heidelberg, Heidelberg,

Germany.

30

Department of Neurology, Odense University Hospital, Odense, Denmark.

31Department of Anesthesiology & Intensive Care, University Hospital of

Grenoble, Grenoble, France.

32BehaviourWorks Australia, Monash Sustainability Institute, Monash

University, VIC, Australia.

33Department of Public Health, Faculty of Health Sciences and Social Work,

Trnava University, Trnava, Slovakia.

34Quesgen Systems Inc., Burlingame, CA, USA. 35

Australian & New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.

36Department of Neurosurgery, Umea University Hospital, Umea, Sweden. 37

Department of Neurosurgery, University of Pecs and MTA-PTE Clinical Neuroscience MR Research Group and Janos Szentagothai Research Centre, University of Pecs, Hungarian Brain Research Program, Pecs, Hungary.

38Department of Medical Psychology, Universitätsklinikum

Hamburg-Eppendorf, Hamburg, Germany.

39Neuro ICU, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico,

Milan, Italy.

40ANZIC Research Centre, Monash University, Department of Epidemiology

and Preventive Medicine, Melbourne, Vitoria, Australia.

41Department of Neurosurgery, Hospital of Cruces, Bilbao, Spain. 42Intensive Care and Department of Pediatric Surgery, Erasmus University

Medical Center, Sophia Children’s Hospital, Rotterdam, the Netherlands.

43

Department of Neurosurgery, Hospital Universitario 12 de Octubre, Madrid, Spain.

44Department of Neuroscience, Azienda Ospedaliera Università di Padova,

Padova, Italy.

45

NeuroIntensive Care, ASST di Monza, Monza, Italy.

46School of Medicine and Surgery, Università Milano Bicocca, Milan, Italy. 47Department of Public Health, Erasmus University Medical Center,

Rotterdam, the Netherlands.

48

Department of Anaesthesiology, University Hospital of Aachen, Aachen, Germany.

49Department of Anesthesia & Neurointensive Care, Cambridge University

Hospital NHS Foundation Trust, Cambridge, UK.

50Movement Science Group, Oxford Institute of Nursing, Midwifery and

Allied Health Research, Oxford Brookes University, Oxford, UK.

51School of Public Health & PM, Monash University and The Alfred Hospital,

Melbourne, VIC, Australia.

52Radiology/MRI Department, MRC Cognition and Brain Sciences Unit,

Cambridge, UK.

53Institute of Medical Psychology and Medical Sociology,

Universitätsmedizin Göttingen, Göttingen, Germany.

54Oxford University Hospitals NHS Trust, Oxford, UK.

55Department of Neurosurgery, University of Pecs and MTA-PTE Clinical

Neuroscience MR Research Group and Janos Szentagothai Research Centre, University of Pecs, Hungarian Brain Research Program (Grant No. KTIA 13 NAP-A-II/8), Pecs, Hungary.

56Brain Physics Lab, Division of Neurosurgery, Department of Clinical

Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK.

57Intensive Care Unit, CHR Citadelle, Liège, Belgium. 58Intensive Care Unit, CHU, Liège, Belgium. 59

Movement Science Group, Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, UK.

60Department of Neurosurgery, Antwerp University Hospital and University

of Antwerp, Edegem, Belgium.

61

Department of Anesthesia & Intensive Care, Maggiore Della Carità Hospital, Novara, Italy.

62Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium.

63Department of Neurosurgery, Leiden University Medical Center, Leiden,

the Netherlands and Departmentt of Neurosurgery, Medical Center Haaglanden, The Hague, the Netherlands.

64

Department of Neurosurgery, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.

65Department of Neurology, Erasmus University Medical Center, Rotterdam,

the Netherlands.

66

Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK.

67Neurologie, Neurochirurgie und Psychiatrie, Charité-Universitätsmedizin

Berlin, Berlin, Germany.

68Neurointensive Care, Sheffield Teaching Hospitals NHS Foundation Trust,

Sheffield, UK.

69Department of Anaesthesiology and Intensive Therapy, University of Pécs,

Pécs, Hungary.

70Departments of Neurology, Clinical Neurophysiology and Neuroanesthesiology,

Region Hovedstaden Rigshospitalet, Copenhagen, Denmark.

71National Institute for Stroke and Applied Neurosciences, Faculty of Health

and Environmental Studies, Auckland University of Technology, Auckland, New Zealand.

72Department of Medicine, Azienda Ospedaliera Università di Padova,

Padova, Italy.

73Department of Anesthesiology and Intensive Care, University Hospital

Northern Norway, Tromsø, Norway.

74Department of Neurosurgery, Hadassah-Hebrew University Medical Center,

Jerusalem, Israel.

75

Fundación Instituto Valenciano de Neurorrehabilitación (FIVAN), Valencia, Spain.

76Department of Neurosurgery, Shanghai Renji Hospital, Shanghai Jiaotong

University/School of Medicine, Shanghai, China.

77Emergency Department, CHU, Liège, Belgium. 78Pauls Stradins Clinical University Hospital, Riga, Latvia. 79

Department of Computing, Imperial College London, London, UK.

80Lee Kong Chian School of Medicine, Nanyang Technological University,

Singapore; and Central Clinical School, Monash University, Melbourne, Victoria, Australia.

81Department of Neurosurgery, Neurosciences Centre & JPN Apex Trauma

Centre, All India Institute of Medical Sciences, New Delhi, India.

82Department of Neurosurgery, Erasmus University Medical Center,

Rotterdam, the Netherlands.

83Department of Neurosurgery, University of Cincinnati, Cincinnati, OH, USA. 84

Department of Neurosurgery, Oslo University Hospital, Oslo, Norway.

85Department of Intensive Care Medicine, Radboud University Medical Centern,

Nijmegen, the Netherlands.

86Division of Psychology, University of Stirling, Stirling, UK. 87

Department of Medical Imaging, St. Olavs Hospital and Department of Neuroscience, Norwegian University of Science and Technology, Trondheim, Norway.

88Department of Neurology, University Medical Center Groningen,

Groningen, the Netherlands.

89National Institute for Stroke & Applied Neurosciences of the AUT

University, Auckland, New Zealand.

90Rehabilitation and Brain Trauma, Turku University Central Hospital and

University of Turku, Turku, Finland.

91Helsinki University Central Hospital, Helsinki, Finland.

92Hungarian Brain Research Program—Grant No. KTIA 13 NAP-A-II/8,

Univer-sity of Pécs, Pécs, Hungary.

93

Department of Intensive Care and Department of Ethics and Philosophy of Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands.

94Department of Psychiatry, Clinical centre of Vojvodina, Faculty of Medicine,

University of Novi Sad, Novi Sad, Serbia.

95

Cyclotron Research Center, University of Liège, Liège, Belgium.

96Emergency Medicine Research in Sheffield, Health Services Research

Section, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK.

97

Institute of Research in Operative Medicine (IFOM), Witten/Herdecke University, Cologne, Germany.

98VP Global Project Management CNS, ICON, Paris, France.

99Department of Neurosurgery, Rambam Medical Center, Haifa, Israel. 100

Department of Anesthesiology & Intensive Care, University Hospitals Southampton NHS Trust, Southampton, UK.

(10)

102Cambridge University Hospitals, Cambridge, UK.

103Cologne-Merheim Medical Center (CMMC), Department of Traumatology,

Orthopedic Surgery and Sportmedicine, Witten/Herdecke University, Cologne, Germany.

104Centrum für Schlaganfallforschung, Charité-Universitätsmedizin Berlin,

Berlin, Germany.

105Intensive Care Unit, Southmead Hospital, Bristol, Bristol, UK. 106

Department of Neurological Surgery, University of California, San Francisco, CA, USA.

107Department of Neurosurgery, CHU, Liège, Belgium.

108Department of Neurosurgery, The Walton Centre NHS Foundation Trust,

Liverpool, UK.

109Department of Medical Genetics, University of Pécs, Pécs, Hungary. 110National Trauma Research Institute, The Alfred Hospital, Monash

University, Melbourne, VIC, Australia.

111

Department Health and Prevention, University Greifswald, Greifswald, Germany.

112Department of Neurosurgery, Emergency County Hospital Timisoara,

Timisoara, Romania.

113Centre Hospitalier Universitaire Vaudois, Lausanne, Zwitserland. 114Department of Intensive Care, Elisabeth-TweeSteden Ziekenhuis, Tilburg,

the Netherlands.

115Department of Systems Medicine, Steno Diabetes Center, Gentofte, Denmark. 116Institute for Molecular Medicine Finland, University of Helsinki, Helsinki, Finland. 117Analytic and Translational Genetics Unit, Department of Medicine;

Psychiatric & Neurodevelopmental Genetics Unit, Department of Psychiatry; Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.

118

Program in Medical and Population Genetics; The Stanley Center for Psychiatric Research, The Broad Institute of MIT and Harvard, Cambridge, MA, USA.

119Department of Radiology, Antwerp University Hospital and University of

Antwerp, Edegem, Belgium.

120

NeuroIntensive Care Unit, Department of Anesthesia & Intensive Care, ASST di Monza, Monza, Italy.

121Department of Anesthesia & Intensive Care, Azienda Ospedaliera

Università di Padova, Padova, Italy.

122Intensive Care Unit, CHRU de Besançon, Besançon, France. 123

Department of Neurosurgery, Vall d’Hebron University Hospital, Barcelona, Spain.

124

Department of Anesthesiology and Critical Care, Pitié-Salpêtrière Teaching Hospital, Assistance Publique, Hôpitaux de Paris and University Pierre et Marie Curie, Paris, France.

125Department of Neurosurgery, Kaunas University of technology and Vilnius

University, Vilnius, Lithuania.

126Rezekne Hospital, Rezekne, Latvia 127

Department of Anaesthesia, Critical Care & Pain Medicine NHS Lothian & University of Edinburg, Edinburgh, UK.

128Department of Physical Medicine and Rehabilitation, Oslo University

Hospital/University of Oslo, Oslo, Norway.

129

Division of Surgery and Clinical Neuroscience, Oslo University Hospital, Oslo, Norway.

130Department of Neurology, Elisabeth-TweeSteden Ziekenhuis, Tilburg, the

Netherlands.

131

Broad Institute, Cambridge, MA; Harvard Medical School, Boston, MA; and Massachusetts General Hospital, Boston, MA, USA.

132Department of Neurosurgery, Odense University Hospital, Odense, Denmark. 133

International Neurotrauma Research Organisation, Vienna, Austria.

134Klinik für Neurochirurgie, Klinikum Ludwigsburg, Ludwigsburg, Germany. 135University Hospital Heidelberg, Heidelberg, Germany.

136

Division of Biostatistics and Epidemiology, Department of Preventive Medicine, University of Debrecen, Debrecen, Hungary.

137Department of Traumasurgery, Leiden University Medical Center, Leiden,

the Netherlands.

138Department of Anaesthesiology and Intensive Care, AUVA Trauma

Hospital, Salzburg, Austria.

139Department of Neuroanesthesia and Neurointensive Care, Odense

University Hospital, Odense, Denmark.

140Department of Emergency Care Medicine, Radboud University Medical Center,

Nijmegen, the Netherlands.

141Department of Physical Medicine and Rehabilitation, St. Olavs Hospital

and Department of Neuroscience, Norwegian University of Science and Technology, Trondheim, Norway.

142

Department of Neurosurgery, University of Pécs, Pécs, Hungary.

143Universitätsmedizin Göttingen, Göttingen, Germany.

144Division of Neuroscience Critical Care, John Hopkins University School of

Medicine, Baltimore, MD, USA.

145

Department of Neuropathology, Queen Elizabeth University Hospital and University of Glasgow, Glasgow, UK.

146Department of Biomedical Data Sciences, Leiden University Medical

Center, Leiden, the Netherlands.

147

Department of Pathophysiology and Transplantation, Milan University, and Neuroscience ICU, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.

148Cochrane Consumers and Communication Review Group, Centre for

Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Melbourne, Australia.

149Department of Rehabilitation, M. Bufalini Hospital, Cesena, Italy. 150Department of Neurosurgery, Kings College London, London, UK. 151

Radiology/MRI Department, CHU, Liège, Belgium.

152Department of Intensive Care, Erasmus University Medical Center,

Rotterdam, the Netherlands.

153Department of Anesthesiology-Intensive Care, Lille University Hospital,

Lille, France.

154Director of Neurocritical Care, University of California, Los Angeles, CA, USA. 155Department of Neurosurgery, St. Olavs Hospital and Department of

Neuroscience, Norwegian University of Science and Technology, Trondheim, Norway.

156Department of Neurosurgery, Kaunas University of Health Sciences,

Kaunas, Lithuania.

157Department of Psychiatry, University of Florida, Gainesville, FL, USA. 158

Interdisciplinary Neuro Intensive Care Unit, Charité-Universitätsmedizin Berlin, Berlin, Germany.

159VTT Technical Research Centre, Tampere, Finland. 160University of Florida, Gainesville, FL, USA.

Funding

Data used in preparation of this manuscript were obtained in the context of the CENTER-TBI study, a large collaborative project, supported by the Framework 7 program of the European Union (602150). The funder had no role in the design of the study, the collection, analysis, and interpretation of data, or in writing the manuscript.

DKM was supported by a Senior Investigator Award from the National Institute for Health Research (UK). The funder had no role in the design of the study, the collection, analysis, and interpretation of data, or in writing the manuscript.

Availability of data and materials

There are legal constraints that prohibit us from making the data publicly available. Since there are only a limited number of centers per country included in this study (for two countries only one center), data will be identifiable. Readers may contact Dr Erwin J. O. Kompanje (e.j.o.kompanje@erasmusmc.nl) for reasonable requests for the data.

Authors’ contributions

EvV analyzed the data and drafted the manuscript and the supplementary tables. All coauthors gave feedback on the manuscript. EJOK supervised the project. All coauthors were involved in the design of the survey and the distribution of the survey. All coauthors gave feedback on (and approved) the final version of the manuscript.

Ethics approval and consent to participate

Not applicable since no patients participated, and the centers have given consent by completing the questionnaire.

Consent for publication Not applicable.

Competing interests

(11)

Publisher

’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Author details

1Department of Intensive Care, Erasmus University Medical Center,

Rotterdam, the Netherlands.2Center for Medical Decision Making,

Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands.3Department of Medical Ethics and Philosophy of Medicine,

Erasmus University Medical Center, Rotterdam, the Netherlands.4Department

of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium.5Department of Anaesthesia, University of Cambridge, Cambridge, UK.6School of Medicine and Surgery, University of Milan-Bicocca,

Milan, Italy.7San Gerardo Hospital, ASST-Monza, Monza, Italy.8Department of

Physiopathology and Transplantation, Milan University, Milan, Italy.9Neuro

ICU Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milano, Milan, Italy.10Department of Neurosurgery, Leiden University Medical Center,

Leiden, the Netherlands.

Received: 2 May 2018 Accepted: 15 October 2018

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Figure

Table 1 Topics covered, related questions for each topic, and response rate per question
Fig. 1 Results of question 13 (Questionnaire 8): Would you consider organ donation after circulatory arrest in a patient in whom mechanical ventilation will be withdrawn, but who is not brain dead?
Fig. 2 Results of question 9 (Questionnaire 8): If the decision is made to withdraw life-sustaining measures, in a patient with high intracranial pressure, but who is not brain dead, would you remove the ventricular drain (for CSF drainage), but continue o

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